Theories and Definitions of Mental Disorder

Introduction to the Definition of Mental Disorder

• The lecture addresses the central question: What is a mental disorder?
• The discussion follows a previous session that introduced a skeptical, anti-psychiatric challenge to the concept of mental disorder.
• The goal is to explore various theories, evaluating their advantages and disadvantages to see if the concept of mental disorder is philosophically and medically defensible.

The Anti-Psychiatric Challenge Recap

• The Skeptical Position: Strong anti-psychiatry suggests there is no such thing as a mental disorder.
• Societal Norms vs. Illness: When we label conditions as mental disorders, we are often just imposing societal norms rather than identifying actual diseases or illnesses.
• Stigma and Damage: The concept has been historically and prolifically damaging, generating stigma against individuals categorized as "disordered."
• Character and Personality: Labeling something an illness of the mind rather than the body casts doubt on a person's entire personality or way of thinking, which can be seen as fundamentally unfair.
• Symptoms to Diagnosis Loop:
  • In physical medicine, the process is: Symptoms $\rightarrow$ Investigation/Tests (blood tests, X-rays, etc.) $\rightarrow$ Identification of Cause $\rightarrow$ Diagnosis.
  • In psychiatry, the process often goes straight from a list of symptoms to a diagnosis.
  • Critique: The diagnosis doesn't explain the symptoms; it merely summarizes and feeds them back to the patient.

The Case for Retaining the Notion of Mental Disorder

• Inability to Abandon the Concept: Completely discarding the idea of mental disorder would require an enormous shift in thought and would prevent us from conceptualizing beneficial ways to help people.
• Severe Real-World Examples: Conditions like severe addiction, schizophrenia, or debilitating phobias (such as those that prevent a person from leaving their house) present as more than just "problems." They appear to be illnesses where something is medically wrong with the mind that requires understanding and treatment.
• Two Primary Strategies for Retention:
  1. Show that mental disorder is identical or closely analogous to physical disorder.
  2. Argue that even if they are different from physical disorders, we have other compelling reasons to keep the terminology.

Mental Disorder as a Physical Brain Disorder

• Core Theory: A mental disorder is simply a physical disorder of the brain; psychiatry is effectively the branch of medicine dealing with the brain as a specific body part.

• Supporting Observations:

  • Disorders are often associated with "chemical imbalances" (e.g., depression) or interruptions in normal brain functioning (e.g., eating disorders).
  • Mental states are widely believed to be the "seat of the mind," correlated with or reducible to brain events.
  • Physical interventions like medication (changing brain chemistry) or surgery can successfully treat mental conditions.

• Objections to the Brain-Only View:

  1. Non-Physical Treatments: Methods like Cognitive Behavioral Therapy (CBT), talk therapy, and lifestyle changes address the mind directly rather than the brain physically, yet they are effective.
  2. Environmental Causes: While the disorder might manifest in the brain, the causes are often external (e.g., stressful jobs). Analogous to "asbestosis" (the condition is in the lungs, but the cause is the external asbestos).
  3. Lack of Empirical Findings: Despite decades of funding, researchers have struggled to find reliable physical biomarkers for mental disorders. There is no consistent blood test or MRI that can diagnose depression, anxiety, or bipolar disorder.
  4. The "Healthy Brain" Paradox: One can have a severe mental disorder with a neurologically "healthy" brain. For example, a psychopath's brain may show differences but is functioning perfectly well in a neurological sense; the disorder is in the behavior and thought process, not a tumor or lesion.
  5. Multiple Realizability: This philosophical concept suggests that the same mental state (e.g., a belief or the state of being depressed) can be produced by various different brain configurations in different people. Therefore, there may never be a unified brain condition that explains a specific mental disorder across all patients.

Mental Disorder as Functional Dysfunction

• The Functional Concept: Concepts defined by their role or purpose.
  • The Pen Metaphor: A pen is defined by its function (writing). Whether it is a "good" or "bad" pen depends on how well it performs that job.
  • The Vice Chancellor Metaphor: Defined by the job of running a university.
  • The Heart Analogy: The function of the heart is to pump blood throughout the body. A heart is dysfunctional if it pumps too much, too little, something other than blood, or nothing at all.
• Application to Mental Health: The clinical concept of "dysfunction" suggests a mental disorder occurs when a part of the mind fails to perform its internal role.
• Evolutionary Mechanisms:
  • Snake Detector: Humans possess an inbuilt mechanism that triggers adrenaline when seeing something slithery (selected for survival).
  • Fear Response: Intended to protect from danger (fight, flight, or freeze). A phobia (e.g., fear of non-dangerous spiders) is a fear response triggered incorrectly.
  • Appetite: Its role is to ensure adequate nutrition; eating disorders represent a failure of this mental mechanism.

Critiques of Evolutionary Functionalism

• Functional Disorders: Some "disorders" might actually be functioning exactly as evolution intended.
  • Psychopathy: It may be a stable evolutionary strategy for men who receive early life cues that they are "low status," shifting them into a rule-breaking mode to propagate genes.
  • Depression: One theory suggests it was selected to force a person to "slow down and reflect" when goals are unattainable, allowing for a change in strategy.
  • Fear of Flying: A fear of heights was highly adaptive before planes existed, preventing people from falling off cliffs.
• The "Natural Selection vs. Well-being" Problem:
  • Natural selection only cares about survival and reproduction ($procreation$).
  • It does not care about happiness, work-life balance, rewarding hobbies, or good friendships.
  • Therefore, a mind functioning as it was "designed" by evolution might be miserable, and what we call "mental health" might actually be "unnatural" in an evolutionary sense.
• Mismatch Theory: The human mind evolved for life as hunter-gatherers on the Savannah, not for student life in a contemporary urban environment like Wellington.

Alternative Theories: Rationality and Pragmatism

• Aristotelian Rationality:

  • Aristotle believed everything has a purpose ($purpose = function$). An acorn’s purpose is to become an oak tree.
  • The distinctive function of a human is to be a "rational animal."
  • Mental disorder, in this view, is a failure of rationality (e.g., emotions that don't match reality, such as feeling guilt when you've done nothing wrong).
  • Problem: This makes mental health an evaluative/ethical issue, which can be subjective.

• The Pragmatic/Practical Theory (Aparly):

  • The function of a diagnosis is not to describe a "natural" state but for practical utility.
  • The Privacy of Mind: Mental states are private and don't show up on X-rays. This makes it easy for others to misunderstand them (e.g., calling a depressed person "lazy").
  • Legitimization: Medical labels (clinical depression, generalized anxiety disorder) provide a way to communicate the reality of an experience to others.
  • Utility: Diagnosis helps in making insurance claims, getting doctor assistance, and gaining understanding from friends and family.

Questions & Discussion

• Student Question: If mental disorders are brain disorders, why are some treatments non-physical (like CBT)?
  • Response: Even non-physical treatments are often framed today as "rewiring the brain," suggesting that talk therapy is still an intervention in brain function.
• Student Question: Does focusing on the brain ignore environmental causes?
  • Response: Yes, but we must distinguish between what a disorder is (the condition in the brain) and what caused it (external factors/environment).
• Student Question: How do we define what is rational?
  • Response: It is difficult and may lead back to being a matter of opinion, but generally includes things like forming beliefs that lead to truth and having emotions that accurately represent the world.